FAMILY ASSESSMENT IDENTIFYING INFORMATION: Date__________________ Parent Name/s _____________________________ _____________________________ Identified Patient_________________________ Age _____ Birthdate ______________ Other family members/relationships and children/ages ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Absent parents, children/ages ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Referral information Areas of concerns or problems Individual and/or family strengths and resources Safety concerns Treatment plan Treatment goal/s and objectives Modality Recommendations INFORMATION GATHERING CONTENT INFORMATION (What to ask): : What is the current problem? Who has the problem? Who is more concerned about the problem? Are any family members in treatment for psychiatric illness, alcoholism or drug abuse? Have there been any crises or significant events in your family which may have contributed to these problems (births, deaths, traumatic events)? What is the family’s idea (theme) about the problem? What has the family tried so far to solve the problem? What does the family expect from therapy? What is the larger context and history of the problem? Who else may be involved? What themes seem to constantly reappear? What sorts of support does the family have (social, familial, church, etc.)? PROCESS INFORMATION (Your observations): How well do the family members communicate with each other (don’t talk, have trouble expressing how they feel, interrupt and don’t listen, etc.?) What are the family members’ reactions to you as the therapist (intimidated, highly sensitive, seductive, skeptical, dependent, passive, angry, aggressive?) How anxious are the various family members? How resistant? What is the emotional range of the various family members? What emotion is each person most comfortable expressing? What’s missing? What patterns do you see (family roles, family dynamics, etc.)?